Presented to the NRHA Rural Primary Issues GroupJuly 24, 2017Washington, DC

Keith J Mueller, PhDDirector, RUPRI Center for Health Policy AnalysisInterim Dean, College of Public HealthUniversity of Iowa

Medicare Advantage Competition for engagement

in Advantage Care Organizations

Medicaid Managed Care Organizations

Medicaid use of ACOs

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Rural Enrollment in 2009: 1.17 million (13.5% Rural Enrollment in 2013: 1.71 million (18.2%) Rural Enrollment in 2017: 2.37 million (23.2%)

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Percent Enrolled by StateUp to 10%10% - 14.9%15% - 19.9%20% - 29.9%30% or more

Source of data: Centers for Medicare and Medicaid Services (CMS) data, as of March 2017Produced by: RUPRI Center for Rural Health Policy Analysis, 2017

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480 Shared Savings Program ACOs in Medicare

44 Next Generation ACOs 12% of ACOs in low population density

counties (0 to 40% in metro) 9 million beneficiaries now receiving care

through ACOs Participating providers include 71 RHCs, 55

CAHs, 65 FQHCs

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Welcome to MACRA: Medicare Access and CHIP Reauthorization Act

Play the wheel of Merit-Based Incentive Payment System (MIPS) with 750,000 physicians

Advantage to those participating in alternative payments models (ACOs that are not sharing downside risk)

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Minimal FFS payment increase 0.5% x 5 years, then 0% x 5 years

Actually payment decrease (inflation) Merit-Based Incentive Payment System Eventually -9% to +27% adjustment in pay

▪ Based on quality, resource use, meaningful use, and clinical practice improvement activities

Up to 36% differential per year!

Plus, up to 10% Exceptional Performance Incentive Payment (budget neutral exclusion)

Or, 5% APM bonus Excluded from MIPS and meaningful use

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275 Medicaid MCOs operating in 38 states 55.2 million enrollees 77% of state Medicaid population

Source: State Health Facts. The Henry J. Kaiser Family Foundation. Accessed July 21, 2017: http://www.kff.org/medicaid/state-indicator/total-medicaid-mc-enrollment/?currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

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10 states actively using this approach 13 more pursuing Most notable: Oregon, Colorado, Minnesota

Source: Center for Health Care Strategies Inc. Fact Sheet June, 2017. accessed July 21, 2017: https://www.chcs.org/media/ACO-Fact-Sheet-06-13-17.pdf

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Pressures: premium price setting, cost-sharing

Results: shift to sharing the insurance risk – with consumers, providers

Consequences: different patterns of use and payment

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Use of value-based contracting

ACOs, again

Push and pull regarding new delivery modalities, including telehealth

Population health a dominant theme, but starting with high users

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Doing different with less

But doing different – break molds cast since 1997 and before

Ideal is all payer system supporting innovation and redesign

But much more likely – communities and providers have to make it happen

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The RUPRI Center for Rural Health Policy Analysishttp://cph.uiowa.edu/rupri

The RUPRI Health Panelhttp://www.rupri.org

Rural Telehealth Research Centerhttp://ruraltelehealth.org/

The Rural Health Value Programhttp://www.ruralhealthvalue.org

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Interim Dean, College of Public HealthGerhard Hartman Professor, Health Management & PolicyDirector, RUPRI Center for Rural Health Policy Analysis145 Riverside Drive, S153A, CPHBIowa City, IA 52242319-384-1503

keith-mueller@uiowa.edu

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The Rural Health Research Gateway provides access to all publications and projects from eight different research centers. Visit our website for more information.

ruralhealthresearch.org

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Center for Rural HealthUniversity of North Dakota

501 N. Columbia Road Stop 9037Grand Forks, ND 58202

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The National Rural Health Resource Center https://www.ruralcenter.org/

The Rural Health Information Hubhttps://www.ruralhealthinfo.org/

The National Rural Health Associationhttps://www.ruralhealthweb.org/

The National Organization of State Offices of Rural Health

https://nosorh.org/

The American Hospital Associationhttp://www.aha.org/

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